Posts Tagged ‘geriatric specialists’

Frail, demented nursing home patients can eventually lose the ability to take food and fluids by mouth. When that process begins to occur tube feedings may be started. Doctors and family members may believe that such feedings prolong life and improve the ability to fight bedsores and disease. Dr. Thomas Finucane, a nationally recognized expert practicing Geriatric Medicine at Johns Hopkins in Baltimore, challenges that easy assumption. In a report for Elder Law Issues, Dr. Finucane explains:

Although it seems implausible, when faced with an emaciated, demented, permanently recumbent, poorly communicative patient with bedsores who is losing weight, clinicians and loved ones should remember there is no good evidence that administering tube feeding will help this patient.

Randomized trials are the gold standard for evaluating whether treatments are effective. Such trials are generally lacking with respect to tube feeding. Other data, some quite persuasive, have been developed, and these studies are virtually unanimous in showing lack of effectiveness.

Several lines of evidence suggest that tube feeding will not prolong survival when compared to a conscientious effort at hand feeding. Death rates are very high in the days and months after feeding tubes are placed.

No published paper suggests that tube feeding will reduce the risk of aspiration pneumonia; several trials find feeding tubes to be risk factors for the development of pneumonia. Aspiration pneumonia usually arises from inadvertent inhalation of either contaminated oral secretions or of regurgitated gastric contents. Tube feeding could not be expected to prevent either of these events.

Pressure sores have not been shown to improve when tube feeding is given. Once feedings are initiated, patients will produce more urine and stool, which are definite risk factors for pressure sores.

Risk of infection has not been reduced among tube fed patients. Serious and fatal infections have been shown to result from tube feeding.

Demented patients have not been shown to get stronger and function better with tube feeding.

Although it is difficult to know the experience of a noncommunicative person, there is no evidence that tube feeding reduces suffering. Restraints are more often used in tube fed patients.

Dozens of serious side effects have been reported as a result of tube feeding. Based on these data, it seems that tube feeding is overused in the care of patients with advanced dementia.

Legal battles over tube feeding have focused on comparing the benefits and burdens of the procedure. Benefits have been assumed, and burdens have usually been limited to the physical pain associated with insertion of tubes. Dr. Finucane challenges both sets of assumptions. He also challenges the medical community to undertake research to determine whether tube feedings really are beneficial.

The U.S. is suffering from a serious shortage of doctors trained to care for elderly patients. A recent New York Times article reported that “while the number of older Americans is rising quickly — particularly those over 85 and in the frailest health — experts say the number of doctors trained to meet their needs is in critically short supply.”

A 1980 study conducted by UCLA projected that by 1990 the U.S. would need 13,000 geriatric specialists to deal with the anticipated elderly population. In fact, the total number of geriatricians practicing in the U.S. today is approximately 4,000, or less than one-third the anticipated need.

The usual explanations for this chronic shortage of geriatric specialists include:

A reluctance by doctors to face aging and death,

Poor reimbursement rates for geriatric medical services, particularly by government programs, and

A shortage of academic leaders and role models in geriatrics.

In addition to the shortage of geriatric specialists, there is a growing problem of inadequate training in geriatric issues for other physicians. Of the 126 U.S. medical schools, only 13 require course work in geriatrics, and only 2 others offer geriatrics as an elective course. Most medical schools cover geriatric issues as part of their general curriculum, but experts say this approach is insufficient given the scope of the training shortage.
There are currently about 32.3 million Americans over age 65. Within the next 40 years, that number is expected to more than double, to about 70 million. At the same time, the number of Americans over age 85 (the frailest elderly, and those needing the most specialized care) will almost triple, from about 3 million to nearly 9 million.

While those over 65 make up about 13 percent of the population, they account for about 30 percent of the nation’s health care costs, 44 percent of all hospital days and 40 percent of all internists visits. While the need for more geriatric specialists seems obvious, the supply is simply not keeping pace with demand.

Nursing Homes, Too

Approximately 1.8 million Americans lived in nursing homes in 1990, according to Census figures. That represented a 24 percent increase during the 1980s, a rate of increase that was approximately double the general population growth rate.

Within the next quarter-century, the number of nursing home residents is expected to more than double. According to projections by the Brookings Institution, there will be four times as many nursing home residents at the end of the next half-century unless there are fundamental changes in the way we deal with the elderly.

About half of the current population of nursing home residents suffer from some form of dementia. The projections for future use assume that the rates of dementia and institutionalization continue about the same in the next half-century. Much of the increase in nursing home population will come from the aging “Baby Boomer” generation, as its oldest members will turn 65 in fifteen years.

Those same “boomers” are just beginning to face the prospect of nursing home placement — for their parents. According to a 1993 Gallup poll, most Americans are more frightened by the prospect of placing a parent in the nursing home than by the prospect of that same parent’s sudden death.

The “boomers” have been characterized as demanding consumers and prepared to shop around more readily than their parents. Their effect on the nursing home marketplace should be interesting to observe.